Meet Consultation Requirements With the Three Rs

CPT includes four types of consultations: office or other outpatient (99241-99245), initial inpatient (99251-99255), follow-up inpatient (99261-99263), and confirmatory (99271-99275). Section 15506 of the Medicare Carriers Manual (MCM) specifies that three guidelines (the Three Rs) must be met to bill a consultation:

1. Request: A physician provides a consult regarding E/M services for a specific problem that has been requested by another physician or other appropriate source (unless it is a patient-generated confirmatory consultation).

Any physician may request a consult from any other physician and may perform a consult for his or her own patient as long as all criteria are followed. An "other appropriate source" is generally understood to mean any individual who can act on the advice/information provided by the consulting physician. According to the MCM, "Limited licensed practitioners, e.g., nurse practitioners or physician assistants, may request a consultation." A school nurse, however, may not qualify, depending on the individual carriers guidelines. Check with the insurer if there is any doubt that an appropriate source has requested a consult.
2. Reason: A request for a consultation from an appropriate source and the need for consultation (medical necessity) must be documented in the patients medical record.
According to the MCM, "In an emergency department or an inpatient or outpatient setting in which the medical record is shared between the referring physician and the consultant, the request may consist of an appropriate entry in the common medical record." In an office setting, there must be a specific written request for the consultation from the requesting physician, or the consultants records "must show a specific reference to the request."

3. Response: After the consultation, the consultant must prepare a written report of the findings that is provided to the referring physician.
Medicare Carriers Manual guidelines specify that the consultation report must be "a separate document communicated to the requesting physician."

- Published on 2002-09-01